Intensive care units in the US treat over 6 million patients each year. One in five Americans dies following ICU treatment, while others survive acute critical illness only to remain critically ill on a chronic basis, with severe functional impairments and dependence. For these patients and for those who survive in better states of health, palliative care (symptom control, patient and family support, effective communication, and treatment aligned with patient preferences) is increasingly seen as an integral component of comprehensive intensive care. Although improvement of the quality of palliative care has been identified as a national health priority, evidence suggests that this care remains deficient in ICUs. Our R21 exploratory research focuses on a new set (a "bundle") of nine process measures of palliative care quality that we have created specifically for the ICU. No such measures were developed previously. Specific Aims are 1) To explore the validity of the new quality of ICU palliative care process measures; 2) To evaluate the feasibility and reliability of these measures for routine data collection through medical record review, which ICUs would couple with performance feedback to caregivers; and 3) To explore associations between performance on these process measures of quality with outcomes valued by patients and families. We will first use qualitative methods (focus groups) to determine what patients and families think is important for ICU palliative care quality and its measurement. We will then measure performance of the care processes in 3 different ICUs, as documented in patients' medical records. We will test the intra- and inter-rater reliability of the process measures and the reliability of medical records as a data source for performance of the care processes of interest. We will also interview ICU families to measure outcomes including comprehension of clinical information, quality of communication, levels of depression and anxiety, satisfaction with care and decision- making/communication, and perceived quality of dying and death. We will explore associations between performance on the new process measures and these patient- and family-focused outcomes. Findings and analyses of this R21 exploratory research will provide the foundation for a larger-scale (R01), randomized, controlled trial of the effect of implementation of the process measures with performance feedback and appropriate system supports on the quality of palliative care in ICUs. N/A [unreadable] [unreadable] [unreadable]